How long should bisphosphonates (bone density medications) be stopped before a tooth extraction?

Bisphosphonate Discontinuation Before Tooth Extraction

The evidence does not support routine discontinuation of bisphosphonates before tooth extraction, as drug holidays have not been proven effective in preventing osteonecrosis of the jaw (ONJ), and the long-term bone effects of bisphosphonates persist for years after stopping the medication. 1, 2, 3

The Controversy Around Drug Holidays

The question of whether to stop bisphosphonates before dental surgery remains highly debated in the literature:

• Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs 1, 4
• However, the alternative view is that a short break in bisphosphonate administration will have no effect, as bone effects of bisphosphonates are maintained for years after treatment stops 1
• Multiple studies have found no evidence supporting the efficacy of pre-extraction drug holidays in reducing MRONJ risk 2, 3

Evidence Against Routine Drug Holidays

The most recent and highest quality research demonstrates:

• A 2020 study comparing 179 patients who continued bisphosphonates versus 286 who discontinued (mean 39 months before extraction) found no significant difference in MRONJ incidence (1 case vs 0 cases, P=0.385) 3
• A 2017 multicenter retrospective study found no evidence supporting the efficacy of a pre-extraction short-term drug holiday from oral bisphosphonates in reducing MRONJ risk 2
• The pharmacologic activity and persistent, long-term effect of bisphosphonates on bone likely limits the effectiveness of drug holidays 5

Risk Stratification by Bisphosphonate Type

The approach should differ dramatically based on the formulation and indication:

Oral Bisphosphonates for Osteoporosis

• Extremely low risk: Less than 1 case per 100,000 person-years 4
• No routine discontinuation recommended 2, 3
• The fracture prevention benefits generally outweigh the minimal ONJ risk 4

Intravenous Bisphosphonates for Cancer

• Substantially higher risk: 6.7-11% incidence in multiple myeloma patients 4
• Drug holiday considerations are more relevant but still controversial 1
• For patients with active cancer and bone metastases, interrupting therapy poses tangible risks of pathologic fractures and spinal cord compression 4

Evidence-Based Prevention Protocol (Instead of Drug Holidays)

Rather than stopping bisphosphonates, focus on these proven strategies:

Pre-Extraction Requirements

• Complete comprehensive dental evaluation before starting bisphosphonate treatment whenever possible 1, 4
• Perform all necessary invasive dental procedures before initiating bisphosphonate therapy 1, 4
• Treat all active oral infections and eliminate high-risk sites 4
• Correct vitamin D deficiency prior to bisphosphonate therapy 4

Surgical Technique Modifications

• Use minimally traumatic extraction technique 2
• Remove any bone edges 2
• Achieve primary mucosal wound closure (OR = 2.51 for increased MRONJ risk if unclosed) 2
• Avoid root amputation when possible (OR = 6.64 for increased MRONJ risk) 2
• Use prophylactic antibiotics perioperatively 4, 6

Post-Extraction Management

• Defer resumption of bisphosphonates (if discontinued) until complete healing is confirmed by the dentist 4
• A 2018 prospective study of 132 patients showed that continuing oral bisphosphonates during extraction resulted in delayed healing (especially >5 years of therapy) but zero cases of BRONJ when proper protocols were followed 7

Clinical Algorithm

For patients on oral bisphosphonates for osteoporosis:

1. Do NOT routinely discontinue bisphosphonates 2, 3
2. Ensure excellent oral hygiene and preoperative antibiotic prophylaxis 5, 6
3. Use atraumatic extraction technique with primary closure 2
4. Monitor healing closely 7

For patients on IV bisphosphonates for cancer:

1. Weigh the risk of ONJ against the risk of skeletal complications from stopping therapy 4
2. If a drug holiday is considered, some experts suggest 2 months prior to surgery 1, 4
3. Use enhanced surgical protocols with antibiotics and primary closure 6
4. Delay resumption until healing is complete 4

Critical Caveats

• Recent dental surgery or extraction is the most consistent risk factor for ONJ, not the continuation of bisphosphonates 4
• Long-term therapy (>5 years) significantly delays extraction socket healing but does not necessarily cause ONJ when proper protocols are followed 7
• Patients should not be discouraged from taking bisphosphonates for existing medical conditions due to dental concerns 5
• The possibility of pre-existing MRONJ in the extraction area must be considered during the procedure 3